A nurse is caring for a toddler who is 24 hr postoperative following a cleft palate repair.
Which of the following actions should the nurse take?
Apply bilateral wrist restraints.
Implement a soft diet.
Administer opioids for pain.
Offer fluids through a straw.
The Correct Answer is C
A. Applying bilateral wrist restraints is not a standard intervention after cleft palate repair.
Restraints should be used judiciously and with clear indications to prevent injury.
B. The baby can start feeding normal diet after 24hrs
C. Administering opioids for pain is an appropriate action by the nurse. Opioids control pain in the immediate postoperative period are followed by administration of acetaminophen PRN.
D. Offering fluids through a straw is contraindicated after cleft palate repair, as it can disrupt the healing process and increase the risk of complications. Sippy cups or other appropriate utensils should be used.
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Related Questions
Correct Answer is B
Explanation
A. While play in the playroom is generally beneficial, providing a specific activity related to the child's distress from the insulin injection is more targeted.
B. Offering a needleless syringe and a doll allows the child to engage in play that mimics the experience of receiving an injection. This can help the child gain a sense of control and understanding of the procedure.
C. A video game may serve as a distraction, but it may not specifically address the child's distress related to the insulin injection.
D. A storybook about a child who has diabetes may provide education and reassurance, but it may not actively engage the child in a therapeutic play activity related to the injection experience.
Correct Answer is C
Explanation
A. The described behaviors, such as sitting quietly and turning away, may suggest the toddler is seeking comfort and self-soothing, which can be indicative of developing autonomy rather than anxiety.
B. Resentment toward the mother is a less likely interpretation of these behaviors, especially considering the age of the toddler.
C. Developing autonomy is a common developmental stage around this age. Toddlers begin to explore their independence and may engage in self-soothing behaviors.
D. Regression is a return to an earlier developmental stage. The behaviors described are more consistent with the development of autonomy rather than regression.
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